Nurse Care Navigator - Quality & Care Transitions

CHRISTUS Health; Irving (TX); On-site; USD 45,000 - 65,000; Full time

Job summary

CHRISTUS Health seeks an LVN/LPN to support care coordination for value-based care programs. The role focuses on improving care gaps, preventive services, and patient outcomes through telephonic outreach and collaboration with ACO/CIN networks.

Strong documentation, communication, and problem-solving are essential as you coordinate with providers and care teams. Responsibilities include scheduling, patient education, and ensuring continuity of care from transitions in inpatient to home, with a

Qualifications

• High school diploma required.
• Minimum of 3 years of clinical or home health experience.
• Knowledge of CMS, accountable care organizations (ACOs), and HEDIS preferred.
• Knowledge of physician office practice operations; 1 year of experience preferred.
• Proficiency in keyboarding and EHR systems, primarily Epic.

Responsibilities

• Meet expectations of OneCHRISTUS Competencies: Leader of Self, Others, or Leaders.
• Identify quality gaps and participate in quality improvement programs.
• Support primary care providers and assist patients in scheduling preventive screenings and appointments.
• Pull reports to identify open care gaps and conduct telephonic outreach to close care gaps and address medication adherence.
• Counsel and educate patients and families using standardized protocols within care transitions and quality metrics.
• Communicate resources and services across the continuum of care.
• Escalate health concerns to providers and place referrals to care team members.
• Document information using standard assessment tools and maintain chart compliance.
• Perform transition of care calls from inpatient or ED to home and coordinate follow-up needs.

Skills

Oral communication

Organizational skills

Adaptability

Problem-solving

Education

High school diploma

Tools

Epic EHR

Job description

CHRISTUS Health seeks an LVN/LPN to support care coordination for value-based care programs. The role focuses on improving care gaps, preventive services, and patient outcomes through telephonic outreach and collaboration with ACO/CIN networks.

Strong documentation, communication, and problem-solving are essential as you coordinate with providers and care teams. Responsibilities include scheduling, patient education, and ensuring continuity of care from transitions in inpatient to home, with a